CH 14, 15, & 22 Practice questions
RN determines CNA knows how to prepare the solution for a soapsuds enema when he states?
"I should use about 1 tsp(5mL). of soap in a L(1qt) of fluid" ---soap is added to the bag after the fluid. (can use tap water or normal saline)--- *too much soap can cause severe pain and excessive cramping and injure mucosa.*
After observing pts sacral area while repositioning her, you document the following: -Intact skin over the sacral area w/a well-defined area of redness 2 cm in width & 3 cm in length. When palpated, area feels boggy and is nonblanching. What is appropriate to add to your documentation of pts sacral area?
"Pt has a STAGE 1 pressure injury."
RN is caring for a pt who has a large abdominal incision. The pt tells the rn that she is afraid to sit up or even move bc of the pain and the strain on the incision site. What instructions should the rn give to the pt?
"Roll to one side, use your elbow as a lever, and push to a sitting position"
RN is reinforcing teaching w/pt who is post-op following abdominal surgery. What instruction should the RN include to ↓risk for wound evisceration?
"Support your abdomen w/pillow when coughing." Splinting
On the day of surgery, most wounds will have what type of exudates?
(S)Sanguineous or (SS)SeroSanguineous
What might dehiscence be preceded by?
(SS)SeroSanguineous drainage.
RN preparing endotracheal suctioning should follow what guidelines?
-Apply suction while WITHDRAWING the catheter. -Use NEW cath each time. -Limit total suctions time to 5 mins.
RN caring for pt w/tracheostomy should provide what interventions?
-Apply the oxygen source loosely if the SpO2 decreases during the procedure. -Use surgical asepsis to remove and clean the inner cannula. -Clean outer surfaces in a circular motion from the stoma site outward.
MD is d/c a pt who has a prescription for home oxygen therapy via nasal cannula. Pt and family teaching by rn should include what?
-Check position of cannula frequently. -Report any nasal stuffiness, nausea, or fatigue. -Post "No Smoking" signs in prominent locations.
How do you explain the nursing actions that help maintain an airtight seal for a wound VAC (vacuum-assisted closure) to your pt?
-Clip the hair along the wound borders. (hair interferes w/the ability of the transparent dressing to form an airtight seal.) -Use strips of transparent film to patch any air leaks. - once you apply the foam and transparent tape and turn on the wound VAC, you can identify small air leaks by listening w/stethoscope or feeling around the edges. -Avoid wrinkling the transparent film while applying it to the foam. (wrinkles in the film interfere w/the ability of the transparent dressing to form an airtight seal.
Rn is evaluating a pt who reports losing control of urine whenever she coughs, laughs, or sneezes. The pt relates a hx of 3 vaginal births, but nor serious accidents or illnesses. Which interventions should RN suggest for helping to control or eliminate pts incontinence?
-Decrease or avoid caffeine. -Avoid alcohol
With appropriate instruction and supervision, which tasks r/t wound care can be delegated to UAP?
-Emptying a closed drainage container. -applying an abdominal binder. -Measuring i&o
What factors increase the risk of UTIs?
-Frequent sex. -Location of the urethra in relation to the anus. -Frequent catheterization.
Home health nurse is assessing whether a pt w/a spinal cord injury would be a candidate for intermittent self-cath. Which criteria would support this choice for this pt?
-Pt understands how to recognize s/s of infection. -pt has the manual dexterity to perform the cleaning and insertion. -pt and family are seeking ways for the pt to maintain independence.
RN caring for pt who has had diarrhea for 4 days. When assessing pt, RN should expect what findings?
-HYPOtension -Elevated temp. -Poor skin turgor
RN is preparing to initiate a bladder-retraining program for a pt who has incontinence. What actions should RN take?
-Have pt record urination times. -Gradually increase the urination intervals. -Remind the pt to hold urine until the next scheduled urination time.
RN is caring for a pt who is on 3 L oxygen per nasal cannula. What tasks can be delegated to a UAP?
-Helping the pt to clean area around nares and ears. Counting the RR and taking the pulse ox reading. -Assisting pt to Semi-Fowlers.
Adolescent pt, 2 days post-op following appendectomy and has DM1. Pt is tolerating regular diet, ambulating, pain meds q6-8hrs reporting pain at level2 after. His incision is approvimated and free of redness, w/scant serous drainage on dressing. RN should recognize that the pt has what risk factors for impaired wound healing?
-Impaired circulation -Impaired/Suppressed immune system.
A pt had just returned from surgery. What are the initial assessments that the rn would make r/t the surgical site?
-Inspect the protective dressing that was placed by the surgical team. -Look at the area around the dressing and record observations. -Check under the pt to make sure that exudate is not pooling.
RN caring for older adult at risk for developing pi. What interventions should RN use to help maintain integrity of pts skin?
-Keep head of bed elevated 30°. -Have pt sit on a gel cushion when in a chair.
RN caring for 82-yo pt in the ED who has an oral body temp of 101°F, pulse=114/min, and RR=22/min. He is restless and skin is warm. What interventions should RN take?
-Obtain culture specimens before initiating anti-microbials. -Encourage pt to rest and limit activity. -Assist the pt w/oral hygiene frequently.
RN assessing pt w/accute respiratory infection that puts her at risk for hypoxemia. What findings are early indications that should alert the RN that pt is developing hypoxemia?
-Restlessness -Tachypnea -Confusion -Pallor
RN educator reviewing the wound healing process should include in the information which alterations for wound healing by secondary intension?
-Stage 3 pressure injury. -Open burn area
RN is preparing to administer a cleansing enema to an adult pt in preparation for a diagnostic procedure. What steps should RN take?
-Warm the enema solution prior to instillation. -Position the pt on the left side w/right leg flexed foward. -Lubricate the rectal tube or nozzle.
Supplies needed for pt on BED REST getting a soapsuds enema are:
-bedpan -IV pole -water-soluble lube -1,000 mL of lukewarm tap water.
Student nurse is obtaining a urine specimen from a pt who has had an indwelling cath for several days. Which actions require correction?
-disconnects the cath from tubing and collects urine in a sterile container. -obtains the urine from the collection bag. -draws urine directly from the cath by using a sterile small needle.
In caring for a pt w/a tracheostomy, what interventions will the rn use to reduce risk for infection?
-evaluate pt for ecevess secretions and suction PRN -Provide constant airway humidification -provide frequent mouth care. -remove water that condenses in equipment tubing. -change or clean all resp. therapy equipment q8hrs.
RNn is caring for a pt w/a tracheostomy. What s/s indicate the need for suctioning?
-gurgling sounds heard during resp. -restlessness or anxiety -emesis in oral cavity -drooling excessive secretions -pt indicated need for suctioning.
To promote pts comfort during the administration of the enema solution, what actions can you take?
-preheat the normal saline solution to lukewarm prior -lube tip before insertion. -point tip of enema tube toward pts umbilicus while inserting.
What are the 4 phases of Wound Healing?
1- Hemostasis 2- Inflammation 3- Reconstruction 4- Maturation
Steps for NG suctioning:
1- adjust O2 (120-150 mmHg) 2- sterile gloves 3- check suction function 4- Hyper oxygenate 5- insert in circular motion w/out suctioning. 6- intermittent suction while rotating. 7- check for secretion clearance.
What are indications for a foley urinary catheterization?
1- relief of urinary retention. 2- measurement of residual urine after urination. 3- presence of an open perineal wound.
The pt has a T-tube in place following an abdominal cholecystectomy. What is the expected output of bile in the FIRST 24 hrs?
250-500 mL
Rn collecting data on pt who is post-op following abdominal surgery and discovers the pt has bowel protruding from the incision. Which action should RN take?
Cover the wound w/Nonadherent Dressing. (nonadherent dressing moistened w/warm sterile normal saline protects wound from infection and further injury.)
When are dressings typically removed by?
2nd to 3rd day.
How many times a week do you change dressings on CLEAN wounds?
3 times a week!
Gastric aspirates have acidic pH values of?
4 or less.
RN caring for pt who is 1 hr post-op following an open cholecystectomy w/general anesthesia. RN should monitor what findings as an indication of hypoxia?
Cyanotic mucous membranes. general anesthesia puts pts at risk for ↓gas exchange due to respiratory depression.
How can a pt obtain a HYPERtonic (fleet) enema?
A fleet enema is an OTC item, found in the same aisle as medications for stomach problems.
RN is a long-term care facility is contributing to the plan of care for a pt who is to receive oxygen at 4 L/min via nasal cannula. What NI should she include in plan of care?
Apply a water-soluble lubricant to the nose prongs. (prevents dying of mucous membranes.)
After abdominal surgery, a pt is at risk for wound stress r/t coughing and moving. What equipment does the rn need to teach pt the self-care measure of splinting?
A pillow or rolled blanket.
Rn is reviewing lab results and sees that the PaO2 level for a 75 yo pt is 80 mmHg. What should rn do FIRST?
Assess pt for s/s of respiratory distress.
Before the digital removal of a fecal impaction, the rn checks the medical record. Which part of the pts hx alerts the rn to be especially observant during the procedure?
Cardiac disease. Digital stimulation can stimulate the VAGUS nerve = can cause bradycardia and hypotension.
RN is curing for a pt who has a heavily draining wound that continues to show evidence of bleeding. Which dressing should RN use to help promote hemostasis?
ALGINATE dressing [help est. hemostasis while providing a moist environment for healing and good absorption of exudate. Doesn't adhere to wound, so unlikely to cause further bleeding.]
What nursing action do you include in pts plan of care once a stage 1 PI is concluded?
Apply a moisture-barrier cream to the sacral area. -moisture-barrier cream helps keep moisture away from the pts fragile skin and helps prevent further breakdown.
RN caring for pt admitted w/multiple wounds sustained in motor-vehicle crash. Understanding pts specific needs during this initial stage of wound healing, the rn should incorporate which in pts plan of care to prevent a prolongation of this phase?
Apply oxygen at 2 L/min via nasal cannula. [following acute injury, the body responds by increasing perfusion to the location of the injury during the INFLAMMATORY PHASE of wound healing. Purpose of this ↑blood supply to the wounds is to transport the O2 and nutrients essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in pts who have a lack of O2 or poor perfusion.]
RN has just inserted a NGT. Pt is coughing and gagging. RN takes a small amt of clear aspirated material and tests it w/color-coded pH paper and the pH is 8. What should the rn do FIRST?>
Ask the pt to speak his name and state his full address. (if pt CANNOT talk, tube is in the airway and should be pulled back or removed.)
RN walks into the room and notices that the pt is anxious, demonstrates labored breathing, and seems to be struggling to get out of bed. What should rn do FIRST?
Assist him to sit upright and calmly instruct pt to take slow, deep breaths.
RN caring for pt who is having difficulty breathing. Pt is lying in bed and is already receiving oxygen therapy via nasal cannula. What is nursing PRIORITY?
Assist pt to FOWLER'S position.
RN caring for pt w/multiple sclerosis and has a chronic nonhealing wound. RN should recognize which medication is known to delay wound healing?
Corticosteroids [they suppress the immune system]
When RN inspects wound, what should be inspected?
Both the Dressing or incisional area AND area Under the pt. (EXUDATE FOLLOWS THE FLOW OF GRAVITY!!)
Which lunch tray is BEST for providing protein, vitamins A & C, and Zinc, (nutrients required for wound healing)?
Broiled seafood(protein/zinc) w/spinach salad(A) and tomato juice.(C)
How is Fluid Retention when irrigating wound avoided?
By positioning pt on their SIDE to encourage the flow of the irrigant AWAY from the wound.
Pt who had abdominal surgery 24 hrs ago suddenly reports a pulling sensation and pain in his surgical incision. RN check the wound and finds it separated w/viscera protruding. What should RN do?
Cover the area w/saline-soaked sterile dressings. Position pt in LOW Fowlers/Supine w/hips and knees bent.
What is dumping syndrome?
Caused by too rapid of an infusion of highly concentrated feedings. (symptoms similar to shock and very disturbing)
RN caring for a pt. w/stage 4 sacral pi with mechanical debridement. What should RN plan for this pt?
Changing dressings using the wet-to-dry method.
RN student is performing urinary catheterization. What should student do FIRST?
Check MD order. -procedure requires MD order, student should check order for purpose, type of equipment, meds, etc.
PT has an indwelling urinary cath. UAP reports that no new urine is collecting in the bad since it was measured and discarded at the beginning of the shift. What should the rn do FIRST?
Check for kinks in the tubing system and reposition pt.
Pt w/an indwelling catheter reports a need to urinate. What action should RN take?
Check patency of catheter.
RN is assessing the insertion site of the pts indwelling urinary cath and notices exudate. What other assessments is the rn MOST likely to perform before notifying MD?
Check the pts temp and draw resh urine from the drainage port. (examine for clarity, color, and odor)
A postop pt who was happy and cheerful earlier now demonstrates restlessness and anxiety. He reports feeling "a little lightheaded." He is mildly diaphoretic and his pulse feels thready. What assessments does the rn perform to ID a suspected complication?>
Checks the pulse rate, BP, and assesses for pain. (hemorrhageing is suspected)
Which instruction will the rn give to the UAP about cath care for the pt?
Clean the urinary meatus and 2 inches down the cath.
RN is replacing the ostomy appliance for a pt whose newly created colostomy is functioning. After removing the pouch, what should RN do FIRST?
Cleanse the stoma and the peristomal skin. To facilitate the RN's assesment of the stoma and the peristomal skin, the RN must remove any effluent adhering to the area.
What does the rn observe during the first phase of healing if fibrin is functioning correctly?
Clot begins to form and bleeding subsides. (hemostasis is 1st phase)
You empty 60 mL of bright-red bloody drainage from the JP reservoir & document. To reactivate the JP drain, you..?
Collapse the drainage bulb fully and secure the seal. -Each time you empty a JP drain, you must re-establish its suction. To do so, squeeze the bulb to let out as much air as possible. When it's fully collapsed, seal the drainage spout to allow the neg. pressure within the device to continue to draw drainage from the wound.
RN is obtaining health hx from a young adult pt who has a colostomy. Pt reports frequent episodes of loose stools over the last month, but has no signs of infection or bowel obstruction. He reports that his concerns about leakage have limited his social activities. What should RN recommend?
Consume foods that are LOW in fiber content. Foods low in fiber help thicken stool. Ex: Rice, noodles, white bread, cream cheese, lean meats, fish, & poulty.
RN collecting data on a pt who is post-op following abdominal surgery and discovers bowel protruding from the pts incision. Which action should RN take FIRST?
Contact the Rapid Response team! The greatest risk to this pt is compromised blood supply to the bowel resulting in necrosis; needs immediate assistance!
RN sees that the pt takes steroids for a respiratory condition. What would be an expected affect of steroids on wound healing?
Decreased inflammatory response.
If pt states somethings has "Given Way", what are they referring to?
Dehiscence!
54 yo. pt had an appendectomy which opened unexpectedly 6 days post-op. When an incision opens like this, it is known as what?
Dehiscence.
RN caring for a pt who has a prescription for a 24-hr urine collection. What action should RN take?
Discard FIRST voiding.
What is the most important thing for the nurse to assess for in caring for an older pt who has a condom cath/
Inspect the skin underneath the cath.
What is a disadvantage of a hydrocolloid dressing?
Does not allow visualization of the wound.
What is an important RN responsibility associated w/a Penrose drain?
Drainage on dressing should be observed, position of safety pin is noted. (penrose drain is an open system made of rubber tubing that does from inside the wound through a surgical stab wound and the drainage is collected on a dressing.)
RN has inserted the urinary cath into the pt and while the balloon is being inflated, the pt expresses discomfort. What should RN do first?
Draw fluid out of the balloon and move the catheter forward.
To address the s/s of the inflammatory phase, what does rn perform?
Elevate the injured part and apply an ice pack as ordered.
In teaching a pt w/a new ileostomy about incorporating preventive strategies at home, what should RN instruct pt to do to prevent excoriation and breakdown of the peristomal skin?
Empty the pouch when it is no more than 1/2 Full. Waiting until the puch is more than 1/2 full ↑risk of leakage. ileostomy effluent is irritaing to peristomal skin, so pts should replace pouch when it is 1/3 to 1/2 full.
While assessing the pts abdomen, you note that the jackson-Pratt drain's reservoir is ecxpanded and 1/2 full of blood. Which is an appropriate action for you to take?
Empty the reservoir. -JP drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is 1/2 full, the suction pressure is diminished. So empty and record amt discarded.
For a pt on a bladder retraining program, which dietary/fluid intervention is best?
Encourage at least 2000 mL of fluid/day.
RN hears in report that a pt receiving tube feedings has been having trouble w/dumping syndrome. based on the report, which action is the RN most likely to perform?
Ensure that the feeding is administered very slowly.
Habit training is?
Establishing a voiding schedule.
What is the RN responsible for during tracheostomy suctioning?
Evaluating pts airway patency AND response to airway suctioning.
On the first day of surgery, how often does the nurse inspect the surfical dressings and what does he or she expect to see?
Inspects q2-4hrs for the 1st 24 hrs and expects to see (S)sanguineous and (SS)SeroSanguineous fluid.
RN is talking w/a pt who reports constipation. When the RN discusses dietary changes that can help prevent constipation, which foods should RN recommend?
Fresh fruit and Whole Wheat toast.
In assessing a horizontal wound you note an opening approx. 10 cm long and 5 cm across at the widest point. The wound base is red in color, moist, and had a rough surface. How do you document the wound?
Granulation. -presence of granulation tissue indicates a healthy, healing wound.
What is transtracheal oxygen delivery especially suited for?
HOME use.
pt in early stages of hypoxia and receiving oxygen therapy. What finding should RN expect from this pt indicating hypoxia?
HYPERtension.
Which pt is MOST likely to benefit from the application of a triangular binder?
Has a possible fracture in the forearm. (triangular binder =sling)
Pt w/full-thickness wound continues to experience considerable pain during dressing changes despite administration of analgesic. Which type of dressings should RN use to minimize pain of dressing changes?
Hydrogel
Pt requires suctioning of pulmonary secretions. What is the most accurate problem statement for this pts condition?
Inability to clear airway. -secretions are obstructing the air passages, suctioning will clear the airway.
Which assessment finding in a pt w/a wound VAC would alert you to a potential wound infection?
Increased exudate in the drainage chamber. [drainage is expected but is typically minimal and SeroSanguineous]
RN is collecting data from pt w/metabolic acidosis. Which type of respirations should she expect?
Kussmaul respirations ↑ in the rate and depth of the respiratory rate to reduce CO2 and lower the pH.
If Evisceration occurs, what position do you remain pt in?
LOW Fowler's w/knees flexed. -reduces pressure on the wound.
You evaluate that the normal saline enemas have had the desired effect when you inspect the commode the pt used and find:
Large amt of slightly discolored solution w/no solid fecal matter. (this is consistent with "clear returns")
RN is administering a return-flow enema to a pt, after instilling 100 mL of enema fluid, rn should...?
Lower the container to allow the solution to flow back out.
During a cleansing enema, pt reports abdominal cramping. What should RN do?>
Lower the enema fluid container.
While an RN is administering a cleansing enema, the pt reports abdoinal cramping. What action should RN take?
Lower the enema fluid container.
What action do you take if pt reports abdominal cramping during a soapsuds administration?
Lower the ht. of the solution bad to slow the instillation rate.
When checking the dressing, you note that the JP drain is intact & draining and that there is also a quarter-sized area of fresh red bloody drainage noticeable on the dressing. What do you do?
Mark the edges of the area of drainage w/tape. -Apply tape to indicate the outer perimeter of the drainage and note the date/time. This helps monitor pt dressing for increasing drainage or signs of hemorrhage.
Rn has just removed a urinary cath from a postsurgical pt. What is the most important instruction to give the UAP?
Measure the amt of the FIRST voiding and report the TIME & AMT. to nurse.
Wound healing is affected by all except: 1- nutritional needs 2- activity 3- rest 4- medication
Medication 1-Nutritional needs 2-Fluids 3-Rest & Activity 4-Preexisting conditions
Which pt is the most likely candidate for an endotracheal tube?
Pt is discovered in the bathroom, unresponsive, and pulseless. ET used in emergency situations to establish an airway for pts who are not breathing.
RN collecting data on pt who is post-op following abdominal surgery. RN should identify that which finding ↑ the pts risk for wound evisceration?
Pt is morbidly OBESE.
What do you do if dry dressing adheres to the wound and why?
Moisten the dressing w/steril normal saline or steril water before removing the gauze. Reduces further trauma!
The rn is preparing to change the pts dry sterile dressing. Upon attempting the removal of the old dressing, it adheres to the site. What should the rn do?>
Moisten the dressing with saline.
Can nasogastric tube removal be delegated?
NOOOOO!
What is the most common type of irrigation?
Normal Saline solution.
What type of solution is used to describe "enemas until clear?"
Normal Saline. (safest solution)
Older adult resident in a long-term care facility is incontinent of urine. RN observes that the resident always asks for assistance to go to the toilet after eating breakfast. Based on this observation, what would the RN do first?
Note times that the resident asks for help to the bathroom or requires changing of underwear. (establishes voiding schedule)
Charge nurse delegates the removal of an indweling urinary cath to a new staff member. Which action requires correction?
Obtaining a final urine specimen from the drainage bag.
Which dressing requires that the RN place tape strips on all sides of the dressing?
Occulsive dressing (prevents air or oxygen from reaching the wound site)
RN must be vigilant for signs of hypoxia in an older pt who has dementia and also has risk for decreased oxygenation bc of chronic respiratory disease and immobility. What is an EARLY sign that warrants additional assessment of respiratory status?
Pt seems restless and anxiously picks at linens.
RN is caring for 4 clients who are 4 days post-op following abdominal surgery. The RN should further assess which pt for a wound evisceration?
Pt who reports feeling his incision separate when he sneezed, coughed, or vomitted.
To maintain your pts safetly and to prevent dislodgement of the drain, you secure the Jackson-Pratt drainage system to the..?
Pt's gown with safety pin.
The RN observes that the dressing over the wound has exudate that has a strong, pungent odor. Which RN action is most important?
Perform a wound culture & notify MD.
In performing nursing skills and procedures for pts, which nursing action demonstrates the nurse's understanding and use of Standard Precautions?
Performs HH before and after every pt encounter.
After a total abdominal hysterectomy, a postop pt develops a wound evisceration. What should rn do FIRSt?
Place pt in LOW Fowler's position to reduce strain on the wound w/knees flexed.
RN is preparing to administer a cleansing enema to a pt who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which is the appropriate intervention?
Place pt in the DORSAL RECUMBENT position on a bed pan. -pt is likely to not retain enema at all.. this helps pt maintain dignity.
What is included in the prep for tracheostomy care in the acute environment?
Placing pt in Semi-Fowler's position. -allows pt to breathe easier and easy access for nurse.
RN is teaching pt how to apply an extended-wear skin barrier. What should RN instruct pt to use for maximal adherence?
Press gently around the barrier for 1 to 2 minutes. The pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.
RN must perform cath care. Prior to starting the procedure, rn raises the bed and lowers one side rail. What is the best rational for this?
Promotes good body mechanics.
The pt begins to cough and gag when the rn inserts a NGT. The rn instructs the pt to breathe easily and take few sips of water, but the pt continues to cough. What should rn do FIRST?
Pull the tube back just slightly and instruct the pt to breathe slowly.
While an RN is teaching a pt how to replace her ostomy pouching system, the pt reports that removing the skin barrier is sometimes painful. What should the rn suggest?
Push the skin away from the barrier while removing it. Pushing the skin away from the barrier helps prevent skin stripping, which can be painful and make the skin sensitive to the adhesive. If the pt is having difficult w/the initial release of the barrier, it may help if she starts in one corner and gently pulls it across the stoma while pushing the skin away from the barrier.
What is the nursing action if dehiscence occurs?
RN should place a Warm, Moist sterile dressing over the area until the MD evaluates the site.
Dehiscence most frequently occurs in what phase?
Reconstruction (3rd) phase.
While irrigating abdominal wound using a slow continuous flush of warmed normal saline solution, you notice that the solution begins to have a slightly pink color and observe that the wound base is bleeding. What do you do?
Reduce the force you are using to flush the wound. & notify MD that the wound bled during irrigation.
The pt needs a breast binder. What is the most important consideration for the rn when implementing this application?
Respiratory function must not be restricted!!!
A pt who is postop is experiencing abdominal distention and is having difficulty expelling flatus. The RN should anticipate receiving an order from the MD for which type of enemas?
Return-Flow
You notify the MD and the risk manager about your pts stage 1 pressure injury. What factors do you include in the list of risk factors for your pt?
Risk factors: -incontinence -previous hx of pressure ulcers healed by scar formation. -impaired cognitive ability. -Braden score below 16 RATIONALS: -incontinence: skin exposed continually to fecal/urinary moisture leads to maceration, and fecal bacteria can cause infection, irritation, and breakdown. -previous hx of pressure ulcers healed by scar formation: areas of skin that have previously had to heal by scare formation are typically not as strong and cannot tolerate pressure as well as areas of undamaged skin. -impaired cognitive ability: Pts who are cognitively impaired cannot always sense when they need to change position and often cannot change position independently. -Braden score below 16: Braden Scale determines pressure-injury risk via 6 subscales: sensory perceptopm, moisture, activity, mobility, nutrition, and friction/shear. Scores range from 6-23. Adults: any score <18 indicated ↑risk.
RN is assessing a PI over a pts right heel area and observes a deep crater w/no eschar or slough and no exposed muscle or bone. What kind of PI is this?
STAGE 3 [full-thickness tissue loss appearing as a deep crater, w/out exposed muscle or bone, may or may not be slough]
What can oxygen toxicity cause?
Scarring of respiratory tract tissues.
The pt returned to the unit 3 hrs ago after having surgery on the abdomen, and the dressing is now saturated w/red, watery drainage. What should rn do FIRST?
Securely reinforce the dressing w/layers of gauze. (will help loosen the crusty exudate)
You remove 60 mL of pale, blood tinges, watery yellow drainage from the JP's reservoir. How would you describe the drainage in the pts chart?
SeroSanguineous. -Plasma mixed w/blood. Thinner and more watery than blood, often yellowish in color, and blood-tinged, (rather than bright red blood and watery like Sanguineous.)
As exudate subsides, it becomes what?
Serous!
What position is appropriate for a horizontal abdominal wound irrigation?
Side-lying. -irrigating solution can flow from one end of the horizontal wound to other and into a basin placed perpendicular to (below) the wound.
RN is caring for pt who is receiving oxygen @ 8 L/min through a simple face mask. RN should identify that the pt is able to receive which concentration of oxygen w/a simple face mask?
Simple Face mask = [40% to 60%] at [5 to 12 L/min]
RN is preparing older adult pt for an enema. RN should assist pt to which position?
Sims- left lateral w/right leg flexed.
RN observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. How would you document findings?
Slough
What does Granulation tissue look like?
Soft, pink, fleshy projections that consist of capillaries surrounded by fibrous collagen.
What technique does Tracheostomy care and suctioning require?
Sterile technique.
The pt has not contraindications for fluid intake. Over a 24hr period, he drank 16 oz of decaf coffee, 10 oz of juice, 6 oz of milk, and a half a liter of soda. What instructions does the rn give the pt about fluid intake to promote wound healing?
Suggests that he drink 2-3 additional 8-oz servings of his favorite fluid every day. (Goal is 2000-2400 mL/day)
Pt had an uneventful hip surgery several days ago and will soon be transferred to a rehab unit. Pt says to the rn, "I feel silly complaining about this but I feel a little SOB and I feel a little anxious and fuzzy headed." Pt has no know hx of resp. or cardiac probs. What should rn do first?
Take VS, apply a pulse ox, and listen to breath sounds.
Rn is assessing the amt of drainage that the pt has from a surgical wound and finds that 650 mL has drained from 9am until now, 11:40pm. What should the rn do FIRST?
Take the pts VS, assess for other symptoms, and inform the surgeon. (amt of drainage is excessive, so rn would assess for hemorrhage or shock)
Pre-op teaching for an older adult pt who has diverticulitis and is scheduled for a creation of a double-barrel colostomy in the sigmoid colon. What should the RN include in the teaching?
Tape a dry gauze pad over the distal stoma to collect drainage. The distal stoma (aka - mucous fistula) secretes mucus; it does not drain feces. A dry gauze dressing is usually sufficient.
rn is supervising an RN student who is doing a wet-to-dry dressing change. What does the rn do when the student applies a dry dressing over the wet guaze?
Tells the pt that the student is doing a good job.
The rn is preparing to remove the pts staples, but after assessment, the rn decides that the staples should not be removed. The decision is based on which finding?
The wound edges were partially separated.
Pt tells the home health nurse that he is doing fine and has been irrigating his colostomy 5-6 times a week with 2000 mL each time. What is the IMMEDIATE concern that needs to be followed up?
The pt needs to have blood drawn for possible low electrolyte levels. -pt is using too much fluid and irrigating too frequently.
Which evaluation stmnt indicates that the polystyrene sulfonate enema was a successful therapy?
The pts serum potassium level is WNL.
RN is caring for a pt who will perform fecal occult blood testing at home. What should the RN explain to pt about the procedure?
The specimen cannot be contaminated w/urine.
Max amt. of enemas "until clear" allowed to be administered consecutively without further instructions from surgeon is?
Three
Dressing for stage 1 pressure injury?
Transparent
RN is applying a dressing over the insertion site of a peripheral IV catheter. Which dressing is best?
Transparent dressing.
What is the best choice of a wound dressing for a pt w/stage 1 PI?
Transparent dressing. -bc skin is intact w/stage 1 pi, a dressing is not always required. but a transparent dressing is an appropriate choice bc it protects the skin from shearing forces and allows easy visualization of the wound.
How long can ostomy appliances remain in place for?
Up to 7 days.
RN is observing a new staff member perform a sterile dry dressing change. The rn would intervene if the staff member performed which action?
Uses sterile gloves to remove the old dressing. (clean gloves are adequate for removing old dressing - DUH!)
RN is planning care for a pt who requires an exact concentration of O2. Which of the following Oxygen delivery systems should RN use?
Venturi Mask Allows a certain amt of rm air to mix w/a set flow of oxygen to deliver and exact concentration of O2. [Venturi mask = O2 at 24% to 50% @ 4-12 L/min]
Very precise oxygen mask?
Venturi mask
A pt had surgery 4 days ago and now reports an increase in pain and has a temp of 101.6°F. The Incision site looks red compared to yesterday and a small amt of purulent drainage is seeping around the suture line. Which lab result will the rn check before contacting the surgeon?
WBC
A nurse is preparing to administer the first of 2 large-volume, cleansing enemas prescribed for a pt in prep for a diagnostic procedure. Which is an appropriate step in the procedure?
Warm the enema solution prior to instillation. -hot fluid = can injure the intestinal mucosa. -cold fluid = can cause abdominal cramping.
When does phagocytosis occur?
When exudate from the injured cell is surrounded, ENGULFED, and digested by leukocytes.
When does wound healing occur?
When skin edges are not close together (approximated) or when pus has formed. ---Secondary Intention (Granulation)------
During the reconstruction phase of healing, what is the MOST serious complication?
Wound dehiscence.
RN is caring for pt who has developed a stage 1 pi in the right ischial tuberosity. What should the RB plan to apply to pi?
Zinc Oxide [barrier cream]
Pt w/bladder cancer tells the rn that, of the various urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. What option would that be?
a Knock's pouch. This is a continent ileal bladder conduit that does not require an external drainage collection device bc the pt self-caths q 2 to 4 hrs to remove urine. This device will provide the control the pt desires.
During cath care, how many inches do you clean from the outside of the cath?
first 2 inches! with soap and water only!
Pt will be performing a self-administering HYPERtonic enema at home the night before a procedure. How long should she try to retain the solution?
for 2 to 5 minutes. [Hypertonic (fleet) enema solution
What is the purpose for irrigating wounds?
for cleansing AND medication administration.
RN is providing pre-op teaching for a pt w/colon cancer. The surgeon informed the pt that his entire large intestine & rectum will be removed. RN explains to pt he will have what type of ostomy?
an ileostomy. After removing the entire large intestine & rectum, surgeon will create an ileostomy to DIVERT feces from the small intestine to the abdominal surface and into an ostomy pouch.
When should you provide analgesics for anticipated pain?
at least 30 mins BEFORE tx.
RN is preparing to administer an oil-retention enema to a pt who has constipation. RN explains that the pt should try to retain the instilled oil for..?
at least 30 mins, but Preferably AS LONG AS HE CAN. (1-3 hours if poss.) -takes between 30 mins and 3 hrs for the oil to exert its therapeautic effect.
How do you assess exudate?
by circling and dating drainage area and comparing the circled area w/later observations.
Serous
clear
purulent
infection
Iatronic is -
infections caused by tx. or procedure.
RN is administering an enema medicated w/sodium polystyrene sulfonate (Kayexalate) to an older adult pt who has hyperkalemia. RN should insert the tip of the rectal tube...?
insert: 3 to 4 inches.
Postsurgical pt has a Salem sump tube for decompression of the stomach. The rn observes fluid leaking out of the pigtail. What should rn do?
introduce 30mL of air into the pigtail to clear the vent, then position the air vent upward.
What is the Yankaurer or tonsillar tip suction catheter used for?
perform Oropharyngeal suctions. ***Sterile technique***
serosanguineous
pink
purosanguineous
pus & blood
How often should INFECTED wound dressings be changed?
q24 hours!
NG tube oral care?
q2hr
Sanguineous
red
Which pt is most likely to need extra teaching about how to protect the skin around an ostomy?
the pt has an ileostomy. (fecal material from the ileostmomy is more acidic and less formed than feces from a colostomy)
What is the PRIMARY purpose for using the Wet-to-Dry method?
to mechanically debride a wound.
After catheter removal, pt should void within how many hours?
void within 8 hours.
RN collecting data from a pt who is 5 days post-op following abdominal surgery. Surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the RN to initiate after collecting wound and blood specimens for culture and sensitivity. What should RN expect to find?
↑ incisional pain. Fever & Chills. Reddened wound edges.
